KNOXVILLE, Tenn.  Everything seemed to be going Tiffany Clay's way. She was 18, bright, attractive and heading off to the University of Tennessee with a scholarship as a highly recruited swimmer.

Tiffany Clay credits Tennessee staff members for helping her deal with the transition to college life.

Krystal Kinnunen-Harris for USA TODAY

Within a month, however, Clay's life was tumbling out of control. She suffered recurring migraines and had difficulty sleeping. Schoolwork, which had been a snap in high school, seemed beyond her. Although her training times were consistent, she lost her mental focus and often went through practices in a stupor.

Clay began partying and staying out late as a release on weekends. "I felt completely overwhelmed," she says. "I didn't realize it, but I was dealing with depression."

The pressures that accompany elite-level college athletics had blindsided her. While the benefits of participating in sports outweigh the risks for most women, colleges report that increasing numbers of female athletes are struggling with depression and anxiety.

"They're supposed to be poster children, but these young women are facing so many issues that people don't realize," she says.

To alleviate some of these pressures, health care providers, colleges and universities across the country are creating support systems designed to be safety nets.

Tennessee's Team Enhance is one of the earliest and most comprehensive. The program was started in 1989 after a female athlete overdosed on diet pills and went into a coma. She recovered but no longer competed. Moshak, who co-founded the program, realized the school had no support team to address the crisis.

Moshak gathered a team of staff members — coaches, nutritionists, sports psychologists and athletic trainers — for a weekend retreat. They locked the doors and talked.

"We started brainstorming about what were the problems, how could we fix them, what were our resources and where could we start," Moshak says.

They began with a nutrition program to deal with disordered eating, a blanket term that covers a spectrum of eating problems.

The program has evolved into a comprehensive network, integrating physicians, athletic trainers, strength and conditioning coaches, sports psychology, a life-skills academic program and clinical counseling, almost all of it on campus.

"The point is to be proactive, not reactive, and have professionals to handle issues with a holistic approach," Moshak says. "We're very quick to handle an athletic injury but not so quick to handle the emotional issues, and we need to be.

"Depression is probably the largest thing we treat because it coincides with a lot of other disorders," she says. "I think it is very under-diagnosed and poorly understood."

Building support systems

When Clay's performance dropped, her coach suggested she see Kristen Martin, a clinical social worker on staff in the women's athletic department. They met weekly for more than a year and still meet periodically.

Three years later, Clay is an All-American athlete, on track to graduate in 2007 and engaged to be married.

"Without Kristen or someone like her, I would have kept everything to myself, and I don't know what would have happened to me," Clay says. "But now I know where I am, who I am and where I'm going."

Universities vary in their approaches to addressing student athletes' psychological needs. Some rely on their medical schools to monitor problems or tap into health care professionals in their communities. Increasingly, schools are finding the most success with treatment provided by an on-campus network.

The University of Oklahoma added sports psychologist Nicki Moore to its staff in summer 2004 after administering a survey designed by the NCAA to assess the needs of its athletes. The most frequent response: a call for counseling, says Moore. By the following December, the number of male and female athletes in counseling had jumped from 8 to 25.

"The top issues that came back from our students were self-esteem, depression, stress management and anxiety," says Moore. "We realized (psychological counseling) had to be part of what we did every day."

Jennifer Carter, director of sports psychology at Ohio State University, says there are days when it seems every student athlete who comes into her office could be diagnosed as clinically depressed. Her three-person staff saw a total of 180 athletes (out of roughly 900) for counseling in 2004-05, both male and female. That's 12% more than the previous year.

"It has increased to the point where 15% to 20% of our student athletes are dealing with major depression," says Carter, an All-American swimmer at Kenyon College in Ohio from 1991-93. "Nationally, I think we're behind the curve in addressing this need. Not many schools have specific resources for mental health."

Women athletes at risk

In the general population, women experience depression and anxiety at roughly twice the rate of men, according to the National Institute of Mental Health. A NIMH study also shows that female high school students have significantly higher rates of depression, anxiety disorders and adjustment disorders than male students.

Colleges that track these issues find that these ratios carry over to their students. Almost two-thirds of the athletes Moore has seen at Oklahoma are women. At Ohio State, 55% of the athletes Carter saw last year were women.

"When student athletes get to school, everything explodes," Moshak says. "All of a sudden, they're on their own, they're under more pressure. They have to step up academically, and now it has to be more than sheer talent that carries them athletically because everyone is good."

Since Congress enacted Title IX of the Education Amendments in 1972 to ban sex discrimination at schools receiving federal funds, the number of high school females competing in athletics has risen from 300,000 to 2.9 million, according to the National Federation of State High School Associations.

At the college level, participation has grown from 32,000 in 1972 to 162,752, according to the NCAA's latest survey in 2004. Women receive athletic scholarships worth more than $1.8 million a year. (About 217,000 male athletes receive $2.1 million in aid.)

But there are drawbacks, too. "The assertion that women's sports are becoming more like men's is true and is not necessarily a good thing in terms of (women's well-being)," Moore says.

Suicide is uncommon but is part of the history of women's college programs. A well-known example is Sarah Devens, a three-sport standout at Dartmouth, who shot herself in 1995. It was the summer before her senior year, when she would have been a team captain in field hockey, ice hockey and lacrosse.

While athletes are often perceived to be mentally tough and able to resolve problems that might lead to depression, just the opposite might be true. Having to handle what is essentially a full-time job and keep up with schoolwork might leave them feeling less well-adjusted than non-athletes.

That's what happened to Ohio State swimmer Morgan O'Connor. Despite enjoying her best results in the pool and excelling academically in industrial engineering last year, O'Connor, 21, says she began to withdraw from friends and teammates, had difficulty sleeping, was on edge emotionally and became indifferent to food. She says her weight loss was "negligible," but her coach asked if she had an eating disorder.

"This coach knew about eating disorders but didn't know much about depression," says sports psychology director Carter. "It's not easy to say what causes depression or what depression is trying to tell you."

After meeting with Carter, O'Connor identified a family history of depression and better understood the demands of her athletic and academic worlds.

"I felt very overwhelmed and stressed out," says O'Connor, who is in the middle of her senior season and on course to graduate this spring. "I bottled everything up and wanted to quit school, even though I loved it."

Meeting the challenge

Convincing some coaches that the mental health of their student athletes is as critical as their physical well-being isn't automatic. Martin says she still deals with a coach who believes that any athlete who needs counseling doesn't belong in Division I athletics.

But Martin says that attitude is rare. Most coaches respond like Tennessee women's basketball coach Pat Summitt: "For me, it means a lot less stress. I know I have experts in the field in areas where I'm not an expert. We have talented people in place who can make a difference."

Moshak's advice to other schools is to build a support system.

"The biggest thing schools have to realize is that the need exists everywhere," she says. "If you think these issues don't exist in your world, you're living under a rock."